The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)
Has a history of alcohol abuse
Bathes three to four times a week
Has a history of diabetes mellitus
Becomes diaphoretic on warm days
is prescribed antidepressant
Has a history of a cerebrovascular accident CVA
Correct Answer : A,C,D,F
A. Has a history of alcohol abuse
Explanation: Alcohol can contribute to hypothermia as it causes vasodilation, leading to heat loss. It can impair the body's ability to regulate temperature.
B. Bathes three to four times a week
Explanation: While personal hygiene is important, the frequency of bathing alone may not be a direct risk factor for hypothermia. The overall environmental temperature and the individual's ability to regulate their body temperature are more critical considerations.
C. Has a history of diabetes mellitus
Explanation: Diabetes mellitus can increase the risk of hypothermia as it may affect circulation and peripheral nerve function. Impaired sensation and reduced blood flow can contribute to difficulty in maintaining body temperature.
D. Becomes diaphoretic on warm days
Explanation: Excessive sweating (diaphoresis) can contribute to the risk of hypothermia, as it leads to moisture loss from the skin, making it more challenging for the body to maintain a stable temperature.
E. Is prescribed antidepressant
Explanation: While certain medications, including some antidepressants, can affect thermoregulation, the prescription of an antidepressant alone does not necessarily indicate an increased risk of hypothermia. It is essential to consider the specific medication and its potential side effects.
F. Has a history of a cerebrovascular accident (CVA)
Explanation: Individuals with a history of a cerebrovascular accident may have impaired thermoregulation due to damage to the central nervous system. This can increase susceptibility to temperature extremes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Use of resistance bands
Explanation: Resistance band exercises can improve strength and flexibility, but they may not specifically address balance as directly as Tai Chi or certain yoga poses.
B. Stretching
Explanation: Stretching exercises contribute to flexibility and can be part of a well-rounded exercise routine. While they can be beneficial, other exercises like Tai Chi and yoga may have a more specific focus on balance improvement.
C. Tai Chi
Explanation: Tai Chi is a low-impact exercise that emphasizes slow, controlled movements, weight shifting, and mindfulness. It has been shown to improve balance and reduce the risk of falls, making it suitable for individuals at high risk.
D. Yoga
Explanation: Yoga incorporates balance, flexibility, and strength exercises. Certain yoga poses can help improve balance and stability, making it beneficial for individuals at risk for falls.
E. Range of Motion (ROM) activities
Explanation: Range of motion activities helps maintain joint flexibility and can contribute to improved balance. Encouraging the client to perform gentle range of motion exercises can be beneficial.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Use cool or tepid water.
Explanation: Using cool or tepid water for activities like sponge baths or cool compresses can help lower body temperature and provide relief from heat.
B. Avoid alcohol.
Explanation: Alcohol can contribute to dehydration. Advising the client to avoid alcohol helps maintain proper hydration levels, which is crucial in preventing hyperthermia.
C. Minimize exertion.
Explanation: Excessive physical exertion in high temperatures can lead to overheating. Advising the client to minimize physical activity during peak heat hours can help prevent hyperthermia.
D. Wear cool clothing such as silk or polyester.
Explanation: Light and breathable fabrics like silk or polyester can assist in keeping the body cool by allowing better air circulation. This helps prevent overheating.
E. Drink plenty of fluids.
Explanation: Staying well-hydrated is essential in preventing hyperthermia. Encouraging the client to drink plenty of fluids helps maintain hydration and regulate body temperature.
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